Lab Data and Diagnostic Medical Transcription Terms / Words For Medical Transcriptionists


NOTE:  Always refer to your normal lab value sheet for normal ranges. The values indicated in this webpage are unique to each patient's specific disease/condition!! 

 
LABORATORY DATA:  White count on admission 9700, hemoglobin 14.4, hematocrit 44.6, and platelets 225,000.  Sodium 140, potassium 4.2, chloride 101, CO2 30, BUN 14, creatinine 1.2, glucose 103, calcium 9.2, total bilirubin 0.7, and total protein 8.1.  AST 195, ALT 116, alkaline phosphatase 120, albumin 4.1, lipase 241, and troponin I is less than 0.1.  Urinalysis shows trace protein, 1+ occult blood, negative nitrites, negative leukocyte esterase, 5-10 red blood cells and less than 2 wbc's, trace bacteria, trace mucus, and rare epithelial cells.  Valproic acid level is 61.6.

EKG showed no ST changes.  Abdominal x-ray showed a possible bezoar and distended loop of bowel.  Chest x-ray showed no acute pulmonary process with a positive gastric air bubble.

 
LABORATORY DATA:  On admission labs, white blood cell count 6.5, H&H 13.5 and 39.1, platelets 251,000, sodium is 134, potassium 4.1, chloride 102, bicarbonate 25, BUN and creatinine 13 and 1.2, and platelet 364,000.  PT 12.2, INR 0.8, PTT 29, D-dimer is 0.43.  Alkaline phosphatase 103, AST was 35, ALT 497.  cardiac enzymes x3 were negative.


LABORATORY DATA:  White blood count 5500, hemoglobin 14.4, hematocrit 40.6, and platelets 234,000.  Sodium 135, potassium 3.7, chloride 103, bicarbonate 25, BUN 5, creatinine 1.2, glucose 107, calcium 8.8, and albumin 4.3.  Alkaline phosphatase 83, AST 65, ALT 68, total bilirubin 0.6.  UA revealed trace blood.  Chest x-ray was normal.

 
LABORATORY DATA:  Laboratories on admission; blood gases show pH 7.39; pCO2 40.5, normal; pO2 60.2, decreased.  O2 saturation 90.8.  Urine drug screening came back positive for benzodiazepines and cannabinoids.  CK, myoglobin elevated.  Troponin was normal.  CBC shows WBC 6800, H&H 12.3 and 39.  Platelets normal at 262,000.  Chemistry profile on admission showed sodium 146.  Rest of the electrolytes are normal.  BUN, creatinine, and blood sugar were normal.  Liver profile was unremarkable.  Dilantin level on admission was 4.3.

LABORATORY DATA:  Laboratory workup showed hemoglobin of 10.5, hematocrit 31.8, WBC count of 7900, and platelet count of 92,000, bands 16 and polys 73.  Chemistry showed BUN of 13.9, creatinine of 2.8, glucose 148, calcium 9.5, albumin of 3.3, SGOT 46, SGPT 56, alkaline phosphatase 202, and anion gap of 10.

X-ray of the chest showed evidence of congestive heart failure.  EKG showed sinus rhythm and left ventricular hypertrophy with ischemia.


LABORATORY DATA:  Chest x-ray done in the ER showed a right lower lobe infiltrate, questionable infiltrate in left lower lobe.  CMP showed sodium 139, potassium 3.6, chloride 102, bicarbonate 22, BUN 11, creatinine 0.8, and blood glucose of 243.  Her CBC showed white blood cell count of 13,900, hemoglobin 13.2, hematocrit of 39.7, and platelets of 234,000.  The poly count was 90.5% and the lymphocytes were 6.4.  Also, the patient's amylase was 74 and lipase 29.  Albumin 4.3.  Calcium 9.3.  AST, ALT, and alkaline phosphatase were within normal limits.


LABORATORY STUDIES:  Initial white count of 6600 with hemoglobin of 13.8 gm%, segs of 78%.  Another white count was 7130 and 7370 and hemoglobin ranging from 13 to 14.7, segs remained increased at 85% and 78%.  Urinalysis showed presence of sugar and a small amount of blood, protein.  No leukocyte esterase, wbc's negative, and bacteria trace.  Subsequent urine was negative.  Admission electrolytes showed sodium 142, chloride 99, blood sugar 156, creatinine 1.4, BUN 14, subsequent BUN was 11 and creatinine of 1.3.  LFTs showed normal studies and the magnesium initially was only 1.21, improving to 1.9 and 2.2.  TSH was 1.33, troponin I was 0.  Urine culture was negative.

A 12-lead EKG showed functioning pacemaker.  CAT scan of the pelvis without contrast was unremarkable.  CAT scan of the abdomen was also unremarkable except for punctate granuloma at the base of the lung.  No ascites.  Abdominal ultrasound showed a tiny 3 mm left renal calculus, which was nonobstructing.  HIDA scan was negative.  Chest x-ray showed low lung volume without any acute disease


LABORATORY DATA:  The patient’s white count today is 13.6 with a normal differential, H&H of 12.2 and 37.8 respectively, 524,000 platelets, sodium of 139, potassium 3.6, chloride 102, CO2 of 29, BUN and creatinine of 16 and 1.2 respectively, glucose of 87. LFTs and lipase are within normal limits. Urinalysis shows 15 ketones, trace protein, otherwise unremarkable.


DIAGNOSTIC AND LABORATORY DATA:  Chest x-ray shows no acute disease process, just some COPD, as read by the attending radiologist. Head CT shows no acute abnormality, some mild atrophy. White count of 8.2 with an H&H of 10.2 and 32.2 respectively, which is her baseline anemia, 296,000 platelets. Sodium 141, potassium 3.6, chloride 110. CO2 of 26. BUN and creatinine of 26 and 0.9 respectively. Glucose of 110. Cardiac enzymes are negative and normal x1. An EKG shows sinus bradycardia with a rate of 46 beats per minute with first-degree AV block, left axis deviation, diffuse ST and T-wave changes without acute ischemic change, and no change from previous. Her urinalysis shows some bilirubin and ketones, but no evidence for infection.


LABORATORY DATA:  Glucose 136, BUN 46, creatinine 1.8, sodium 141, potassium 4.2, chloride 106, CO2 of 22, AST 16, ALT 15, alkaline phosphatase 182, calcium 9.6, bilirubin 0.4, total protein 7.2, albumin 4.5, anion gap is 12, and lipase is 20. White count 8.4, H and H 9.8 and 28.2, and platelet count is 196. Prothrombin time is 44 with INR 5.0 and PTT of 82.4. Urinalysis, specific gravity 1.020, pH of 6, moderate blood, reds 3-5, otherwise, negative. 


LABORATORY DATA:  The patient’s white count today is 6.2 with an H&H of 13.2 and 39.6 respectively. Sodium 129, potassium 4.6, chloride of 104, BUN and creatinine of 13 and 0.9 respectively. Glucose is 74. LFTs and lipase are all within normal limits. Urinalysis is contaminated, but does not show evidence for infection. Urine hCG is negative for pregnancy. Wet prep is negative for trich or yeast, positive for clue cells.


LABORATORY AND DIAGNOSTIC DATA:  The patient has a renal panel that showed a sodium of 139, potassium 3.6, chloride 104, CO2 of 24, BUN 14, creatinine 0.9, glucose 110. CBC showed a white count of 10.8, H&H of 13.8 and 42.6 and a platelet count of 350,000. Troponin I is less than 0.10. Urinalysis is negative. Serum ethanol level was 62. She has a head CT, which showed atrophy and white matter changes, but no intracerebral hemorrhage and no mass effect. The patient had a chest x-ray, which showed a prominent right hilum, but no infiltrates. She had a cervical spine x-ray, which showed some extensive degenerative spondylitic changes, but no gross fracture or subluxation. 


LABORATORY DATA:  Lab work shows a white count of 6.2, H&H 12.2 and 37.4, platelet count is 204,000, 2 bands, 63 neutrophils, 23 lymphocytes. Urinalysis, catheter specimen, many bacteria, large leukocyte esterase, large blood, trace ketone. Glucose 100, protein greater than 300, reds 20-50, whites too numerous to count, specific gravity 1.025, glucose 232, BUN 25, creatinine 4.6, sodium 134, potassium 4.2, chloride 96, CO2 is 30, calcium is 10.2, anion gap is 11. Urine is sent for culture. The patient did have blood cultures sent.

PERTINENT LABORATORY DATA:  On admission, CBC was 13.1.  Hemoglobin and WBC were fine.  Then, followup of the hemoglobin was down to 11.2.  Urinalysis was unremarkable.  BMP and electrolytes were normal.  BUN was a little bit high at 20.  Creatinine was a little bit high at 1.4.  Blood sugar was 172.  I did not do the followup.  The kidney function was done, back to normal.  Blood sugar was down to 72.  Electrolytes were unremarkable.  Magnesium level is low at 1.8.  The blood gases on admission; the pO2 was 76 with normal pH and pCO2.

We did a KUB on admission.  No change in position of the right ureteral stone at the level of the sacroiliac joint.  Chest x-ray:  The heart is normal, no active infiltrate.  EKG showed regular sinus rhythm.  No fascicular block or evidence of any acute changes.  Cardiac enzymes were unremarkable.


TEST RESULTS:

1.  Chest x-ray:  Cardiomegaly, otherwise unremarkable.
2.  CT of the abdomen and pelvis revealed circumferential diffuse wall thickening of the colon, most likely Clostridium difficile colitis and prominent cardiomegaly, otherwise unremarkable.
3.  CT, pelvis part; diverticulosis of sigmoid, thickening of the entire colon and rectosigmoid, Clostridium difficile colitis.
4.  White blood cells on hospital discharge down to 7400, hemoglobin 12.1, and platelets 275,000.  Sodium 135, potassium 4, creatinine 0.5.  Digoxin level is 0.9.  ALT is 31-39, normal.

 
LABORATORY AND X-RAY DATA:  At the time of admission, the patient had leukocytosis.  At discharge, her white blood count was normal.  Her hemoglobin had gone from 10.1 on admission to 9.5 at discharge.  Diagnosis of probable iron-deficiency anemia had been made.  The patient was found to have elevated fasting glucoses.  Her electrolytes were normal.  Admission urinalysis showed a trace of glucose, large ketones, and trace leukocyte esterase.

Chest x-ray showed some right minor fissure thickening with no acute cardiopulmonary disease.  Final pathology showed a portion of the cecum and appendix with gangrenous appendicitis, perforation, formation of periappendiceal abscess, and a portion of the large bowel with submucosal edema, mural and subserosal, acute inflammation without any evidence of malignancy.

 
LABORATORY STUDIES:  Electrolytes were normal.  BUN 17, creatinine 1.2, and blood sugar 99 mg%.  Magnesium 1.8, troponin 0, digoxin level was 0.69, subsequent troponin level remained 0.  PT was 12.6 with INR of 1.1.  White count was 9880 with 76% segs.  Urinalysis was unremarkable.

A 12-lead EKG showed functioning pacemaker.


LABORATORY STUDIES:  Sodium 133, potassium 4.2, and BUN 24.  Random blood sugar was 147 mg%.  Troponin I was 0.  Blood sugar 144.  T4 was 6.4.  TSH was 1.57, which is normal.  Initial white count was 20,000 with hemoglobin 17.9 mg%, hematocrit 53 mg%, 85 segs.  Repeat white count 2 days later was 11,400 and later this came down to 8400.  Urinalysis was negative.  Subsequent BUN went up to 36 mg% with creatinine of 1.3.  His PSA level was 3.2.  A repeat ABG showed pH of 7.37, pCO2 of 44, and pO2 of 114 on 36% of oxygen.  The urine culture did not grow any organism.

A 12-lead EKG on admission showed supraventricular tachycardia.  Followup EKG showed sinus rhythm with heart rate down to 83 per minute without any acute changes.  Chest x-ray showed chronic obstructive pulmonary disease with granulomatous lung disease and a tiny, small pleural effusion.  No definite pneumonia.  Renal ultrasound showed no evidence of hydronephrosis.  There was a 5.7 simple cyst in the right kidney.  Bladder ultrasound showed postvoid of 340 mL, which is very significant.

 
LABORATORY EXAMINATION:  Hemoglobin 12.3, hematocrit 35.5, white blood cell count 4070, and platelet count of 164,000.  Sedimentation rate of 5.  UA shows no blood, no protein, no nitrites.  Sodium 142, potassium 4.5, chloride 102, CO2 31.5, BUN 17, creatinine 1.1, glucose 88, protein 6.7, albumin 3.8, calcium 9.3.  Bilirubin 0.51, AST 14, ALT 31, alkaline phosphatase 85.  Amylase 48 and lipase 180.  Triglyceride 88, cholesterol 164, HDL 53, LDL 93.  PSA 1.78.  Iron 125, TIBC 344.  B12 of 247, folic acid of 14.  Herpes zoster IgG was 81, herpes zoster IgM was 15.  Serum protein electrophoresis was normal.  Urine culture was negative.


LABORATORY EXAMINATION:  Hemoglobin 10.3, hematocrit 32, white blood cell count 10,800, and platelet count 384,000.  UA showed no protein, no blood, and no glucose.  Sodium 142, potassium 3.2, chloride 103, CO2 of 25, BUN 9, creatinine 1.2, glucose 107, protein 6.1, albumin 2.9, calcium 8.2.  Bilirubin 0.4, AST 16, ALT 37, alkaline phosphatase 87.  Amylase 96, lipase 547, repeat lipase 494.  Magnesium 1.4.  Iron 24, TIBC 282.  C-reactive protein 16.  CEA 2.2.  RPR negative, rheumatoid factor negative, ANA negative, pH 7.35, pCO2 34, pO2 80, and bicarbonate of 19.  Urine negative.


LABORATORY EXAMINATION:  Hemoglobin 10.1, hematocrit 30.6, white blood cell count 2090, and platelet count 98,000.  Sodium 142, potassium 4.1, chloride 106, CO2 of 26, BUN 18, creatinine 1.1, glucose 97, protein 8.1, albumin 3.7, calcium 9.3.  Bilirubin 0.91, AST 69, ALT 55, alkaline phosphatase 134.  Triglycerides 84, cholesterol 140, HDL 47, LDL 76.  T4 of 13.3.  UA showed no glucose, no nitrites, no protein, and no blood.  TSH was 1.21.


LABORATORY DATA:  The patient's labs showed white count of 24,900, hemoglobin was 10.8 gm, platelets 372,000, 86 segs and 9 lymphos.  Eight days later, white count was 15,600, hemoglobin 10.7 gm, and platelets 574,000, 56 segs and 36 lymphos.  PT and PTT were normal.  Urinalysis showed increased number of wbc's and blood was positive.  Repeat urinalysis was essentially unremarkable.  Sodium on admission was 129, potassium 4.6, chloride 93, CO2 of 28.6, glucose 134, BUN 18, and creatinine 1.4 mg%.  Liver profile was normal.  Serum iron was 20, TIBC was 144.  Folic acid was 24 and B12 was 2000.  Repeat sodium was 141, potassium 4.3, chloride 99, CO2 of 31, glucose 101, BUN 14, and creatinine 0.7 mg%.  ABG after admission; pH 7.39, pCO2 46, pO2 73, bicarbonate 27.8, saturation of 94% on room air.  Ferritin level was 515.  Protein electrophoresis was unremarkable.  Iron level and ferritin were not consistent with iron deficiency.  Blood cultures and urine cultures were negative.

Chest x-ray showed no active infiltrate.  Chest x-ray showed chronic obstructive pulmonary disease.  Renal ultrasound was negative.  EKG showed normal sinus rhythm with nonspecific ST-T changes.


LABORATORIES:  Basic metabolic profile done on the day of admission was normal with BUN and creatinine of 7 and 0.2 respectively.  Urinalysis was normal on hospital day #3 and the urine culture collected on hospital day #3 has grown no organisms till today.  Due to the febrile peak, CBC was done on hospital day #3 that showed white count of 5200, H&H 11.3 and 32, and a platelet count of 242,000, differential of 16 neutrophils, 15 bands, and 58 lymphos.


LABORATORIES AND IMAGING:  CT brain showed parenchymal bleed, right occipital pole, approximately 1.3 cm x 8 mm.  CT brain later showed mild resolution of hemorrhage.  No mass effect.  Renal ultrasound was negative.  Laboratories:  Hemogram, discharging hemogram, WBC 18, hemoglobin 11.7, hematocrit 34.6, and platelets 421.  Neutrophils 36, lymphocytes 49, bands 2, monocytes 13.  CRP negative.  Urine culture negative.  UA negative.  Basic metabolic panel:  Calcium 10.4, sodium 141, potassium 4.5, chloride 105, CO2 of 22, BUN 11, creatinine 0.3, and glucose 84.


More Lab and Diagnostic Data Terms & Transcription Samples


LABORATORY DATA:  White count 9.8, hemoglobin 13.2, hematocrit 39.4, essentially normal.  Chemistry profile showed glucose 98, BUN 15, creatinine 0.9, sodium 136, potassium 3.8, chloride 102, CO2 of 24, AST 26, ALT 24, alkaline phosphatase 92, calcium 9.6, direct bilirubin 0.1, total bilirubin 0.5, total protein 8.4, albumin 4.3, anion gap 6.  Amylase 28, lipase 8.  Urine pregnancy test, which was ordered from triage, was negative.  Urinalysis showed small blood, 3 to 5 rbc’s and 20-50 wbc’s and many bacteria with 3 to 5 epithelial cells.  Urine drug screen was positive for benzodiazepines, THC and opiates.


LABORATORY DATA:  Today, white count 7.8, hemoglobin 9.9, hematocrit 29.4, platelets 316,000. Sedimentation rate 106. BNP is 3340. Glucoses are stable. Electrolytes yesterday; sodium 136, potassium 3.6, chloride 94, glucose 101, BUN 52, creatinine 1.4, calcium 8.0, total protein 6.2, albumin 2.2. SGOT 58, SGPT 68, alkaline phosphatase 104. Magnesium level 1.8. Yesterday, CBC, white count 9.2, hemoglobin 10.4, hematocrit 30.8, platelets 224,000. BNP 4290. The patient is responding to diuresis. Urine culture with no growth. Urinalysis unremarkable. Ammonia level was checked because of the patient’s confusion; it was normal at 8.

Chest x-ray showed mild cardiomegaly and central vascular prominence, previously patchy right lower lobe is less appreciated. Stable right arm PICC line. Iron studies; ferritin 548, iron 184, TIBC 170. As noted previously, the patient’s troponin levels were elevated and are slowly coming down. CT showed no acute intracranial abnormality, bilateral basal ganglia lacunar infarct, generalized cerebral atrophy. Echocardiogram was performed showing mild left ventricular enlargement and severely reduced left ventricular systolic function and the regional wall motion abnormality suggests underlying coronary artery disease, which is a known finding in this patient.


And Some More Lab Section Samples


LABORATORY DATA:  Per emergency room revealed the following; CBC, white count 5.2, hemoglobin 12.2, hematocrit 36.4, MCV 91.4, platelets 286,000, polys 77.4, lymphs 19.4, monocytes 2.4, eosinophils 0.6, basophils 0.2. Pro time 27.2, INR 2.82, aPTT 54.6. Sodium 131, potassium 3.2, chloride 88, CO2 of 26, BUN 40, creatinine 2.2, glucose 106. Calcium 8.6, total bilirubin 0.7, SGOT 20, SGPT 52, total protein 6.9, albumin 3.2, globulin 3.6. Amylase 26, lipase 164. Urinalysis; color, yellow; appearance, hazy; pH 6.2; specific gravity 1.012; protein 300 mg/dL; glucose, negative; ketones 10; blood, small; nitrite, negative; bilirubin, negative; urobilinogen, normal; leukocyte esterase, large; rbc’s 30; wbc’s, full field; bacteria, large.

CT scan of the abdomen and pelvis without contrast reveals that there was a left urinary stent placed with left hydronephrosis. The hydronephrosis has not changed since the previous exam. On the right, there was a nephrostomy tube and a urinary stent. The nephrostomy tube enters at the medial margin of the kidney and appears to directly enter the renal pelvis. Loops of small bowel in the pelvis appear mildly dilated. This is similar when compared to the previous exam.


Yet More Lab Data Section Words & Phrases


LABORATORY DATA:  Initial EKG revealed a sinus rhythm with an unusual P axis.  There was also accelerated AV conduction as well as bifascicular block, which was a right bundle branch block and a left anterior fascicular block.  Initial CBC revealed a WBC of 8.2 with a hemoglobin of 9.4, hematocrit of 29.2 and platelets of 172,000.  Potassium 3.0, sodium 138, chloride 104, CO2 of 26, BUN 28, creatinine 3.0, albumin 1.6, calcium 8. Alkaline phosphatase 63, ALT and AST were 58 and 401, total bilirubin was 1.0. Glucose was 180. CK was 254, globulin of 4.2, CK-MB of 1.2 and troponin was 0.14.  Urinalysis revealed +3 albumin, pH of 7, specific gravity of 1.020, leukocyte esterase +2, positive nitrites, +2 bilirubin, +1 ketones, +3 occult blood with normal urobilinogen, +2 bacteria and 10 to 20 urine rbc’s and wbc’s were greater than 50.  Sputum smear revealed occasional epithelial cells and gram-positive rods with gram-positive cocci and yeast.  Wound cultures included positive cultures for Candida of various species as well as vancomycin-resistant Enterococcus.


LABORATORY DATA:  White count is 5800, hemoglobin is 9.6, hematocrit is 27, and platelet count is 216,000.  Chem-7 is within normal limits.


PERTINENT LABORATORY DATA:  On admission, the lipid tests revealed cholesterol of 203, LDL was 132, and triglyceride was 181.  Urinalysis was unremarkable.  CBC was unremarkable.  Electrolytes were unremarkable, except for blood sugar at 131.  The amylase on admission was 250 and lipase was 5833.  On followup of the LFTs, they were normal.  Followup of the amylase, down to normal, and the lipase was 667.  The abdominal ultrasound of the gallbladder showed sludge-filled gallbladder with fatty infiltrate of the liver.  No evidence of acute cholecystitis.  On the nuclear HIDA scan, no evidence of cystic duct or common duct obstruction.  CT scan of the abdomen was unremarkable.  Chest x-ray was unremarkable.


LABORATORY EXAMINATION:  Hemoglobin 12.1, hematocrit 35.6, white blood cell count 4040, and platelet count of 167,000.  Sodium 138, potassium 3.7, chloride 105, CO2 of 25, BUN 12, creatinine 1.1, glucose 85, protein 9.5, albumin 3.4, calcium 8.8.  Bilirubin 1.14, AST 64, ALT 66, alkaline phosphatase 133.  Triglycerides 76, cholesterol 231, HDL 80, LDL 136.  Vancomycin trough 12.1.  Blood cultures x2 showed no growth.  Urine culture showed no growth.
     

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